Oral Health Assessment - California Department Of Education (Page 2 of 2) in pdf

Oral Health Assessment - California Department Of Education Page 2

Section 3- Waiver Request Form

Waiver of Oral Health Assessment Requirement

To be completed by a parent or guardian requesting to be excused from this

requirement

I request that my child be excused from the oral health assessment requirement for the

following reason: (Please check the box that best describes the reason.)

□ I am unable to find a dental office that will take my child’s insurance plan.

My child is covered by the following insurance plan:

□ Medi-Cal/Denti-Cal

□ Healthy Families

□ Healthy Kids

□ None

□ Other __________________________________

□ I cannot afford an oral health assessment for my child.

□ I do not wish my child to receive an oral health assessment.

Optional: other reasons my child could not get an oral health assessment:

California law requires schools to maintain the privacy of students’ health information. Your

child’s identity will not be associated with any report produced as a result of this requirement.

If you have any questions about this requirement, please contact your school office.

Signature of parent or guardian

Date

Return this form to the school by May 30

Original to be retained in child’s school record.

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Oral Health Assessment - California Department Of Education Page 2